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4 Signs of Surgeons' Inattention in the OR

 |  By cclark@healthleadersmedia.com  
   September 30, 2010

We all know that the more often a doctor performs a procedure, the better the chances of a good surgical outcome. The more experienced providers who specialize in one or two procedures, all the time, at specialty hospitals, usually perform very very well.

But like any repetitive routine, doing the same operation over and over can become old and boring. Doctors and nurses on the team play the same music, tell the same jokes and gossip and perform the same steps in the same order.

And sometimes, a dangerous trance, or "drifting" can set in.  Reporting in the October issue of Academic Medicine Canadian researchers dissected just that process, which they call "automaticity." 

Engaged in conversation about the kids or the car in for repairs, doctors can make critical surgical errors that are hard to correct. Such mishaps, even among the most experienced high-volume practitioners, are more likely to take place at those times, according to lead author Carol-anne Moulton, MD, assistant professor of the Department of Surgery at the University of Toronto.

"Errors...occur because routinization leads to automatic behaviors that are not accompanied by close attention," Moulton and co-authors wrote. "Often the only evidence of drifting in these situations is when errors occur."

The article, entitled "Slowing Down to Stay Out of Trouble in the Operating Room: Remaining Attentive in Automaticity," doesn't refer to a temporal slowing down, but rather a refocusing of attention to grapple with the emerging problem.

"It's the routine cases," they quoted one surgeon they observed in their study of this phenomenon. "It's like the...bile duct injuries always happen in easy gall bladders, right? That's what happened here. It was an easy case. We were chatting and obviously not being as diligent as we should have been."

Even in the best of surgeons this sort of rote performance behavior easily can set in. 

In this study, the researchers interviewed 28 surgeons at four academic medical centers and observed five surgeons who specialize in stomach, duodenum, pancreas, liver, biliary tract, and intestine surgical procedures as they operated between 2007 and 2009.

What they discovered was four behaviors the doctors exhibited, either subconsciously or proactively, at rough spots or surprises during the procedures to transition from normal routine to a more "effortful" or "situationally responsive" mode.

Moulton wrote that it's important during training that surgical students and residents recognize these behaviors as moments when they should pay more attention.

"If trainees do not detect the staff surgeon's more subtle transitions or slowing down moments ... they are less likely to appreciate the subtle nuances that require cognitive effort and minor readjustments," she wrote. "This has obvious implications for teaching and training, and may be one reason why some trainees seem to plow through procedures, failing to slow down appropriately." 

These are the four telltale behaviors of automaticity or drifting:

1. Fine tuning. The surgeon continues to engage in extraneous conversation or pauses momentarily to focus on the operative procedure.

2. Focusing more intently. The surgeon withdraws from extraneous conversation or distraction but proceeds without removing or controlling the environmental distractions.

"The surgical fellow had just divided the bile duct during a standard Whipple procedure and was engaged in an extraneous conversation with U2 playing in the background. The surgeon noticed some bleeding and dropped out of the conversation, focusing intently on what they had just divided." Meanwhile the fellow continued talking and the resident and medical student in the room "were literally nodding their heads to the music."

3. Removing distractions.  The surgeon removes distractions, including visitors. He may turn off music and ask that conversations cease.

"The situation was relaxed and proceeding uneventfully. The resident, holding a retractor, was telling an unrelated story to the surgical team with the surgeon laughing in response to her story and joining in the discussing.  In the operative field, a large hepatic vein was opened suddenly, causing a moderate and steady flow of blood loss. Oblivious to this, the resident continued talking. The surgeon said, "Wait one minute. Let's just see where we are." Without the situation fully under control, the resident resumed talking. The surgeon said with some agitation, "Wait one minute, a bit too much bleeding here."

4. Stopping. The surgeon stops the operative procedure.

"As the (surgical) fellow was transecting the liver parenchyma, the surgeon, recognizing unusual anatomy, said 'What the hell is that? Let's just stop and see how we're doing here.' The surgeon then placed his hand in the field to prevent the fellow from operating and looked up at the ceiling for a few seconds with his eyes closed."

"When the researcher asked what he was thinking, he (half) joked, 'I am looking at the textbook on the ceiling.'"

A fifth behavior, called inattentive automatic state" was also observed when the surgeon failed to make a transition as required. Interestingly, many of the surgeons interviewed vehemently denied that they ever entered an automatic mode while operating.  But some apparently do.

"While the surgeon assisted the fellow in this more mundane and routine part of the procedure, the surgeon and trainee engaged in extraneous conversation. Returning to the porta hepatis, the surgeon placed the right angle around the bile duct, forgetting, for the moment, the aberrant artery that had been delicately dissected out 30 minutes before," the researchers recounted.

"Unknowingly the artery was tied off with the bile duct....the surgeon explained tat it was normally such a routine part of the procedure, and admitted to being distracted by conversation."

When surgeons allow themselves to drift, "they fail to engage in the essential monitoring activities that allow them to detect the cues that will initiate a slowing down event," the researchers wrote.

Co-authors are affiliated with the University of British Columbia in Vancouver, the Schulich School of Medicine and Dentistry at the University of Western Onario and Mount Sinai Hospital in Toronto.

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